A new report to Congress recommends steps to ease the secure sharing of patient information, paving the way for better coordination of care and improved patient outcomes. For example, the report recommends the creation of incentives to help overcome the "blocking" of data exchange or reluctance to participate.

Although the federal government has spent $31 billion so far on HITECH Act incentives for hospitals and physicians to "meaningfully use" electronic health records systems, Congress has been scrutinizing whether the investment has paid off in enabling the sharing of health information.

Some security and privacy experts say that while the report spotlights some of the key barriers to secure health information exchange, some of the concerns may be overstated.

For instance, Micky Tripathi, CEO of the Massachusetts eHealth Collaborative, says intentional information blocking among healthcare providers is generally not a widespread problem.

"There are bad apples in every group of humans, and healthcare providers are no exception," he says. "In my experience, malicious information blocking for competitive purposes is very, very rare, and is certainly not a big factor or even a major factor impeding health information exchange. The biggest impediment to information exchange up until now has been lack of demand. That has changed, and now that we have strong demand, we're seeing the market respond and I expect interoperability to grow dramatically over the next couple of years."

The report delves into the various technical, operational and financial challenges that the healthcare sector faces in achieving health information exchange. Among the issues related to privacy and security listed in the report are:

Misunderstanding about HIPAA and other privacy laws has led some to refrain from sharing information.

Applying privacy laws that were originally designed to address paper-based processes to today's electronic transactions has been problematic.

Designing electronic systems and rules to accommodate varying state privacy and security laws has been challenging.

Develop and enhance incentives that drive interoperability and data exchange, such as by focusing on delivery of coordinated care. For example, payers could decline to reimburse for medically unnecessary duplicate testing that could have been avoided if information was shared.

Set payment incentives to encourage health information exchange. Include specific performance measurement criteria and create a timeline for implementation.

Convene a summit of major stakeholders co-led by the federal government and the private sector to act on ONC's recently unveiled 10-year interoperability roadmap.

Information Blocking

Drilling down on the report's recommendations pertaining to payment incentives to help accelerate interoperability, the HIT Policy Committee specifically addresses the problem of information blocking, which involves healthcare providers refusing to share of clinical information.

Sometimes information blocking is related to misinterpretations and misunderstandings about HIPAA and other privacy laws, the report notes.

"There are many examples where misinterpretations of complex privacy laws inhibit providers from exchanging information that is permitted under HIPAA," the report notes. "Also, many providers do not fully appreciate that the HITECH Act gives patients the right of electronic access to their EHR-stored information. As the Centers for Medicare and Medicaid Services defines new payment incentives ... it should incorporate mechanisms that identify and discourage information blocking activities that interfere with providers who rely on information exchange to deliver high-quality, coordinated care."

Other Recommendations

The document also outlines some previous recommendations made by the HIT Policy Committee to ONC, including:

Provide guidance about best practices on the privacy considerations associated with sharing of individuals' data among HIPAA covered entities and other community organizations;

Guide efforts to establish "dependable rules of the road" and to ensure their enforceability in order to build trust in the use of healthcare big data.

Overcoming Privacy Hurdles

David Whitlinger, executive director of the Statewide Health Information Network of New York - the state's health information exchange - says privacy and security issues clearly represent some of the biggest hurdles to overcome before achieving nationwide data exchange.

"Privacy and security regulations vary across different states, and those difficulties are exacerbated even more in sharing sensitive health data, such as mental health, substance abuse, HIV, reproductive health, and information about minors," he says. EHR platforms don't easily support compliance with varying laws when data is exchanged, he notes.

But he points out that industry players are discussing the use of various technologies that "tag" sensitive information so that patients have more control over what part of their health records can be shared among healthcare providers. Also under discussion are policy issues such as "giving patients complete control over their data, so that they ultimately make the decisions about what subsets of data they'll share," he notes.

Tripathi says the biggest barrier to health information exchange, from a privacy and security perspective, "is the heterogeneity of privacy rules that any particular provider faces, which has a paralyzing effect on electronic information exchange."

For instance, in Massachusetts, HIV and genetic test results require consent from patients for each disclosure, he notes. "So even though a Direct [secure email] transaction doesn't require any special consent, certain types of payloads may trigger other consent requirements. So ... as a healthcare provider ... I will hesitate to send out anything until I understand which laws pertain and whether that data my EHR sends triggers any of those other laws."

What's Next?

Members of Congress now must decide whether to act on the HIT Policy Committee's various recommendations.

An aide to Sen. Lamar Alexander, R-Tenn., chair of the Senate Committee on Health, Education, Labor and Pensions, says in a statement provided to Information Security Media Group: "Sen. Alexander is focused on making electronic health records something that physicians and hospitals look forward to instead of something they endure, and he looks forward to hearing what recommendations [the HIT Policy Committee] outlined in [the] report."

While the report notes that steps could be taken to begin implementing various recommendations within the next six months, some healthcare IT experts say it could take years for comprehensive health information to be securely and readily exchanged among healthcare providers by using health information exchange organizations and EHR systems.

Busy physicians and office managers usually don't look forward to going through the hiring process. Not only are they concerned about finding the right candidate for the position, but it is an arduous process that can drag on and impact their ability to keep the practice running smoothly during the interim.

Here are fifteen tips on what you can do to hire right, the first time.

Before the interview

1. Review the job description.

To determine whether or not the job description needs to be revised, review the job description with the employee who is leaving to learn if the job responsibilities have changed. In the process you may discover that some tasks listed are redundant or can be automated.

2. Look for internal candidates.

Let staff know you are on the search and ask if they know someone who might be a suitable fit. You'll also want to open the position to internal staff that may be qualified and looking to climb the ranks. Just be sure they go through the same process as outside candidates to ensure you get the best person for the job.

3. Post the position as soon as possible.

Electronic job postings are quicker and cheaper, and tend to draw the best results. Your hospitals and medical societies may have job boards on their websites. The costs to post on Craigslist, LinkedIn, Indeed, and other classified job search websites is reasonable and yields an immediate posting.

4. Use employment applications.

Require applicants to complete an employment application that asks questions not answered in a resume, such as ending pay rate and the reason the applicant left each position. You can also ask for a list of professional and personal references, and require a signature allowing you to contact past employers.

5. Act quickly.

When candidates with impressive resumes respond to your ad, cull them quickly and don't postpone the interview. Applicants are on the move and the good ones get snapped up quickly. Also, you want to get someone hired as soon as possible, to allow time for proper orientation and training.

During the interview

1. Review job applications prior to interviewing.

Jot down any employment voids or other questions that come to mind when reviewing the applicant's resume, and be sure to address them during the interview.

2. Ask open-ended questions.

The results of the interview itself will be more effective if you allow the employee to relax and become engaged. Ask open-ended questions and pose problem-solving scenarios to identify their approach to resolving conflicts and determine how well they communicate.

3. Ask about strengths and weaknesses.

Ask job candidates what they see as their greatest strengths, what areas they feel they may need to improve on, and what makes them unique as a candidate.

4. Discuss salary with strong candidates.

For those candidates that are rating well during the interview, review the job description and discuss their salary expectations.

5. Communicate follow-up process.

End with letting candidates know what your follow-up process will be and when you will be making a decision.

After the interview

1. Don't skip reference checks.

Do not assume conducting past performance reference checks are a waste of time. Human resource departments may refuse to answer many of your questions, but if you obtain the applicant's permission to contact previous immediate supervisors you can learn a lot. Make the phone call efficient: verify dates of employment, pay rate, title of position, attendance record, and ask the key question, "Would you rehire this person?"

2. Don't ignore red flags.

If candidates don't interview well or if they give vague or contradictory information they should not be considered for employment.

3. Don't postpone the essentials.

Be sure all human resource details are handled the first day of work: hiring forms signed, benefits explained, policies reviewed, etc.

4. Address training needs upfront.

Failure to establish training goals and assign a trainer, or failing to meet with new employees regularly (during their first month) to discuss their progress or assuage their concerns, can sabotage results.

5. Roll out the welcome mat

Your medical practice is a thriving and busy environment. Don't let a new employee feel like he has been thrown in the lion's den. Start off by announcing the new person to existing staff members. Ask every one of your providers to introduce themselves to a new employee, during their first encounter. Keep communication open and give your new staff members the training, respect, and support they need to succeed.

On a recent morning, like pretty much every morning, my e-mail inbox was full of pitches for seminars, webinars, consulting, software, marketing, and handbooks on improving patient engagement, customer service, patient relations, and a host of related treatments for symptoms that can be cured with a smile and a little common sense. Bet yours was, too.

The one thing those digital bromides missed completely is what patients want most — for you to be there when they need you.

Access to care is overwhelmingly the top patient complaint, and desire. If that seems like an impossible wish to fill in your overburdened, rushed, and demanding schedule, you are missing the solution, an opportunity and insurance to preserve your independence.

The old "doc-in-a-box" is now a corporate cookie cutter "NP-in-a-box." The looming threat about how low-cost hospital and chain store mini-clinics will cause everything from patient poaching to relationship dilution to disruption in continuity of care is only seeing a glass as half full without realizing that you own the house that it's in.

You already own the box and you have a built-in advantage: you and your patient base.

Whether or not you decide to put strategies into place to extend your practice's services, at least do these things:

• Always keep a slot or two open each morning and afternoon for patients that need to be seen now; they will be filled or you will run on time, not a bad outcome either way.

• Educate your patients as to what an emergency is, and is not, when you relentlessly promote your new accessibility policy.

• When you say what you will do, do what you say. Virtually every patient is paying out of pocket for your services to one extent or another; most whole dollar. Their expectations have changed accordingly.

Now for the strategies to employ as an extension of your practice:

Strategy 1:"Call Us First!" Whether you use an answering service or forward non-office hour calls to a designee's cell phone, your office should be the first call, e-mail, or text a patient makes (texting is the best option — and a designated phone that is passed on to on-call personnel makes it easy, immediate, and less intrusive).

Strategy 2: Extend office hours. If you are a primary-care provider, you are the most vulnerable, especially if you are in a value-based program. Losing control of downstream dollars is money out of your pocket. Losing patients to other, more convenient providers will be your undoing. It's a new world, and it will be dominated by ease of access to care. Use the first strategy as cover.

Strategy 3: Transform your office into a dual urgent care. Really, this is just an extension of your practice and triage, but you get paid a premium for providing the service, and, your patients will love you.

Obviously, this is just brushing the surface. If you don't know what to do, you can easily find a peer or consultant to help you.

If you don't want to do it, well, you'll be bumping into your patients at the local big-box, pharmacy, or grocery store a lot more frequently. Just look for them at the in-store clinic.

One last thing: promote, promote, promote. The local NP-in-a-box will.

After a long eight years, unemployment has declined to near pre-recession levels. But, also during that time, the healthcare industry has significantly shrunken its footprint — reducing medical staff in response to downward market forces and declining reimbursements. For many small independent practices, that means doing "more with less," a mantra they have been embracing for several years.

Susan Apold is an adult nurse practitioner who has practiced for 18 years as part of a small, solo-physician practice in New Rochelle, N.Y. It is the type of practice she likens to the fictional medical practice of Marcus Welby, MD. "We know our patients, we know their history, they have been with us for many, many years, and are doing quite well," says Apold. Yet, low reimbursements and limited staff and resources to invest in billing and coding hamper the practice's financial viability, she says.

"[In] this practice there has been a lot of conversation about whether this is a sustainable model, because [other local physicians] were selling their practice and joining larger groups," she says. But the practice survives, Apold adds, in part due to her ability to see her own patients and free up the physician to bring in additional revenue — through seeing hospital and nursing home patients.

Your practice likely struggles with the same issues. To help, we asked our experts to tell us how smart staffing can help a practice become more productive and efficient. Here's what they said.

BUILDING A STRONG FOUNDATION

In our seventh annual Physicians Practice Staff Salary Survey, we heard from 1,066 physicians and practice administrators nationwide. The majority still say they are in a traditional, fee-for-service practice. Seventy-six percent of respondents employ one to five physicians. And43 percent of respondents say they made no changes to their staffing levels over the previous year, while 32 percent say they increased workload without increasing salary. Add to that fact, two-thirds of respondents say they have not given their staff annual raises, except to cover the cost of living, and you have a rather dismal picture for staff.

To stay solvent, that means practices need to work smarter, and refine staff roles so that all employees are working to the top of their license. Practices must also become more efficient, eliminating redundant tasks, and training staff to take on more complex roles. That sounds like a tall order, but if you break down the tasks into smaller steps, you'll be amazed at what you can accomplish. Here are a few places to start:

• Hire right, the first time. Charlene Mooney, a consultant with management firm Halley Consulting Group, says one of the worst mistakes that practices can make is to "hire the first person off the street," because they are in a rush to staff an open position. Very often that strategy backfires, as a poor hire can cost the practice time, money, and flagging staff morale. Mooney advises practices to review potential candidates closely and always involve physicians in the interview process.

• Let staff work to the level of their license. Having worked her way up through the ranks as a staff nurse and clinical manager, Liz Yankello has served as practice manager at Sewickley Valley Pediatric & Adolescent Medicine (SVPAM), based in a suburb of Pittsburgh, for the past 15 years. She says the practice culture at SVPAM is a bit unique because the physicians "want to support staff to be knowledgeable, and to use that knowledge in the office setting to the best of their ability." In practice, that means staff members are allowed to take on greater responsibilities for patient care; albeit within the scope of their medical license.

• Find the right number of staff, for the right role. Consultants will tell you that the most effective practices have greater staffing ratios. So does SVPAM. "We are one of the only practices [in our area] that consistently has an RN staff or [a licensed practical nurse (LPN)] staff," says Yankello. In fact, SVPAM staffs seven RNs, four LPNs, and two advanced practice nurses, along with three certified medical assistants to "work adjunctively" with the nurses. Yankello says the cost of employing nurses more than recoups itself by allowing the physicians to see more patients, and be more effective in their care. For example, the "check-in nurse" collects vital signs, family and social history, developmental history, dietary history, the chief complaint, etc., and enters that data into the EHR before the physician even sees the patient.

• Employ advanced practitioners. Advanced practitioners are a hot ticket nowadays; over 60 percent of our survey respondents said they employ at least one NP or PA. It makes sense. Apold says that there are a number of advantages to working with an NP. "You have increased [patient] volume, physicians are free to do the work they were trained to do, [and] practice at the top of their licenses, and it ultimately generates more money for the practice," she says.

SMART MANAGEMENT STRATEGIES

When we asked our survey respondents what their greatest staffing challenges were, they said lack of staff training/subpar skills; lack of professionalism among staff; conflict among staff; and low staff motivation. With the exception of staff training, the rest of these problems can be addressed by communicating clear job expectations, conducting frequent staff reviews, and prompt remediation for lagging staff, says Mooney. Here's how to approach each of these areas, and a few more to ensure your staff is happy, motivated, and efficient.

Job descriptions

Good communication is vital to good job performance. Most managers would tell you this. But in the hurly-burly of daily practice, it is often forgotten. So too are employee job descriptions. But, if an employee does not have a clear idea of what is expected of her, how can she do her job well? Mooney says that she frequently finds job descriptions missing. "I say to a manager, 'How can you write someone up when you haven't told them what's expected of them?'" Mooney recommends letting staff know what's expected of them; holding them accountable for their performance; and if necessary, addressing poor performance promptly. Bad attitudes and sloppy performance will negatively affect the rest of your staff; they can even contribute to losing top staff members. Mooney says she has no problem getting rid of a problem employee. "I see offices let things go on, either because they are afraid to lose the person, or the person has been there a long time, or is a friend of the manager," she says. "But when you have a problem employee … it is very bad for morale."

IN SUMMARY

Declining reimbursements mean less money to compensate existing staff, and to hire new staff. Therefore, practices must utilize staff to the top of their license, and create processes to maximize efficient operations. Here are key areas to watch:

• Hire right the first time.

• Provide staff with clear job expectations.

• Give frequent praise and feedback.

• Consolidate tasks to increase efficiency.

• Use a team-based approach to patient care.

Staff reviews

Performance reviews are not always a favorite among employees, but done well, they are instrumental in achieving stellar performance. Mooney says that periodic get-togethers, two to three times a year, are better than just one annual meeting. That gives the manager and employee a chance to discuss what's going on in the practice, and address areas that may pose problems. Even a simple, "How are you doing?" and, "Do you have any ideas on how we can improve?" can work wonders for enhancing work flow. Taking that concept a step further, Mooney likes to promote what she calls a "critical incident appraisal." That could mean on-the-spot kudos for an employee who was especially helpful to a patient, or talking to a chronically late employee. She says managers shouldn't forget to put a brief note in the employee's file, so that information will be available during the annual review.

Super-trained staff

Deborah Walker Keegan, president of healthcare consulting firm Medical Practice Dimensions, Inc., says the current trend in staffing models is flexibility. "We are really trying to staff a process and not be so people dependent," she says. "There is a lot more cross-coverage and cross-training, and multi-tasking of the staff; particularly in the smaller practices …" Walker Keegan recommends having a "super-trained" staff member of the team who can handle a number of tasks when another person is out sick. So, for instance, a medical assistant can not only work in the back with patients, but also "work the front desk, manage the telephones, and conduct check-out," when necessary, she says.

Process streamlining

Many times, practice work flows grow up through necessity, not by planning. They can sometimes become ungainly, and absorb more time than they really should. One concept that Walker Keegan recommends is to take a look at the number of "desks" you have in your practice, and eliminate those that are unnecessary. By this she means taking a look at the number of tasks that happen during the patient visit, and consolidating as many as possible in a single location. She suggests letting the MA appoint patients for routine follow-up appointments while they are still in the exam room; thus eliminating the need for the patient to queue at the check-out desk. Walker Keegan says that this type of streamlining reduces the number of desks that need to be staffed, and "is a delighter for patients who don't have to travel throughout the practice. The work is brought to the patient …"

Staff appreciation

Busy physicians can be so focused on patients that they fail to let their staff know they are appreciated. But thanking staff isn't just about being "nice," says Mooney, it is vital to retaining your best staff members. "I found that it is not just what you pay someone, it is how they are treated [that incents staff to stay]; how they feel, are they part of the team, how are they motivated, valued, and appreciated," she says. And don't worry; appreciation can come in small packages. Mooney says it can be something as simple as ordering pizza for an impromptu lunch, or greeting staff members personally in the morning. Yankello says each of the staff members at SVPAM gets a gift on her birthday, every year. "We sent them to a spa one year. This year they got an extra half-day vacation day," she says.

While I was preparing a talk on work-life balance, I stumbled across a 2014 article in Harvard Business Review by Stewart Friedman. It is worth reading for all those in search of work-life balance, although he argues that the whole idea of balance is the wrong way to approach the issue. Mr. Friedman articulates the concept of work-life integration: instead of viewing yourself being pulled in different directions (work, family, self), you consider how the various parts of your life overlap and integrate.

In the article, he describes several different exercises that can help you consider your own ability to integrate the personal and professional arenas, as well as identifying the skills you will need to achieve improved integration. What I like about his method is that there is not a "one size fits all" approach in which it is verboten to check e-mail at the dinner table or zone out on your morning commute. Instead, he challenges his readers to experiment, test, and explore what works best for each individual.

So, over the past week, I've been considering my own work-life integration. Truthfully, it still feels like a balancing act rather than a friendly merger. However, by using some of his exercises, I can report a recent success. In January, I changed from a primarily clinical to a primarily administrative/leadership role in my organization. One thing I failed to consider as carefully as I should have was the time demands for "after-hours" meetings and events. With young children at home, I am fiercely protective of the dinner time to bed time window. As a physician, I am used to being at work late or being called back to the hospital, but these demands somehow feel better than skipping dinner just to attend a meeting. Patient care can occur at all hours, meetings shouldn't.

My promise to my family and myself was to limit my late evenings to once a week. However, I started the month of April with seven or eight requests already and became concerned about my ability to be professionally and personally successful. I started with a heart-to-heart with myself. Truthfully, my amazing stay-at-home husband could handle it if I was away from home more often than just once per week. While I was concerned about childcare/homework/bedtime items, I knew that it was more than that. The fact is, I love my family and enjoy spending time with them. Even if it is just being silly around the dinner table or watching DVDs of old 80s sitcoms that my kids love now as much as I did then, that time can be the best part of my day. I am not willing to give it up, even for career advancement.

I concluded that my first resolution was the right approach — a maximum of four evenings per month. Next, I reviewed the invitations and requests on my time and determined that I needed to both prioritize and strategize, first on my own, and then with my boss. I am happy to say I was successful on both fronts, and now feel that I am achieving a balance between professional and family demands.

Desire to succeed at work can easily eclipse family obligations. But this physician found a way to integrate both goals into her life.

The modern version of Shakespeare's classic question "To be, or not to be?" is "To e -mail, or not to e -mail?" With so many choices at our fingertips — from telephoning to text messaging to e-mailing — it can be hard to ascertain which manner of communication is best.

The fact is they all work well. The key is to know what mode to use under which circumstance. While one person may respond immediately to your e-mails, another may allow your notes to linger in his inbox for days because he would rather correspond via text, meet face-to-face, or talk on the phone.

Nowhere is clear communication more essential than in healthcare. One verbal blunder or electronic error can have catastrophic effects. Here are three suggestions to help you effectively interact with others.

1. Declare your preferences.

The best way to begin streamlining your communication is to let people know how they can best connect with you. Naturally, your preference will vary depending on the situation. If it's necessary for you to keep a record of your discussions, then it's advisable to correspond electronically. You can establish this standard by saying, "Let's connect via e-mail so we've got some notes to refer to." That way there will always be a thread to follow if required for medicolegal or administrative reasons. E-mail is also the favored way to share links and connect people with one another. Sometimes, though, only a verbal conversation will get the results you're after. In these cases, arrange a telephone or in-person meeting. Text messaging should be used primarily for notifications and casual conversations that don't need to be preserved as part of a medical record.

2. Ask others how they want to correspond.

Efficiency is a priority when interacting with other people, especially busy medical professionals. That's why it helps to develop a "communication agreement" with patients and colleagues by asking this simple question: "What's the best way for us to stay in touch on this matter?" You'll find that some people will provide you with their private cell phone number and others will ask you to reach them through their assistant or office manager. However you're asked to connect, honor it. Concurring on a method of communication at the beginning of a professional relationship will save everyone time down the road.

3. Maintain a high level of professionalism.

No matter how you choose to communicate — whether it's on the phone, in an e-mail, or via text — view every single message you deliver as a piece of formal correspondence that will live on in perpetuity. The last thing you want is for a casual, off-the-cuff comment you share to resurface in the wrong place with the wrong people at the wrong time. A commitment to preserve the integrity of your professional and patient relationships should underlie the tone of every digital and personal conversation you have. That, coupled with your duty to maintain confidentiality, is what will set you apart as a respected professional.

As time goes on the methods we use to communicate with one another will continue to evolve. But one thing that will never change is the value of sharing your expertise with clarity, compassion, and respect.

Starting with a new EHR system or switching vendors requires hours of training — something many physicians are reluctant to do. However, switching EHRs is sometimes a necessary step to successfully attesting to meaningful use.

Understandably, physicians get frustrated about having to learn a whole new EHR system, so practice managers and administrators have to approach training delicately.

"I think that some physicians have felt over the years that they may not have gotten everything that they needed from their vendor from a partnership standpoint and may not have gotten it in a timely enough manner," said Trenor Williams, managing partner at The Advisory Board's consulting and management division.

Williams added that integrated technology solutions are, "one of the things that clinicians, administrators, and their operators are thinking about and, to me, that's one of the major drivers that we're seeing outside of meaningful use to get physicians to think about changing their electronic health records."

According to a 2014 survey by Medical Economics, 67 percent of physicians are dissatisfied with their EHR's functionality. However, recent research from the American Academy of Family Physicians showed physicians who did switch their EHR vendors were not necessarily happier about their new purchase. Out of 305 physicians who changed EHRs, 43 percent said they were happy with their new software and only 39 percent were pleased with the new system as a whole.

EHR TRAINING 2.0

Whether implementing a new EHR system due to an acquisition or another scenario, according to Bill Fera, principal in the Advisory Health Care practice of Ernst & Young, it's best to tread lightly when training on a new system is required.

"As with any implementation, the approach should be tailored to the persona of the physician," Fera said. "Physicians who had trouble adapting to an EHR the first time around, will probably have trouble again and will probably exhibit a greater level of frustration. They will need more time and attention for training."

Mary Griskewicz, senior director of healthcare information systems for the Health Information and Management Systems Society, said the initial training on an EHR takes about two days. "Then reinforcement of about two weeks to three weeks of using it over and over again is what is typically needed," Griskewicz said. "Having an expert user on hand is best as well as peer-to-peer training, when possible, to train the staff."

Another factor causing practices to change EHR vendors is the need for enterprise-wide functionality, Fera said.

"Practices who were ahead in selecting EHRs often chose ambulatory-specific products that may not be easily integrated into an enterprise strategy," said Fera. "As the industry emphasizes hand-offs and seamless transitions for patients from one care venue to another in the context of re-emerging risk based payment models, the consistent flow of information through an enterprise related to all aspects of a patient's care become paramount. In these cases, physician practices are often being switched to an enterprise product for ambulatory care."

Griskewicz said some of the resistance to training by physicians is because they don't want to take time away from seeing patients.

"Sometimes what [practices] will do is shut down for a couple of days or do appointments in the mornings and then do training in the afternoons where they'll shadow either with the super user or another physician," she said. "Giving clinicians time to learn the system is really important. There's no way around that."

Studies show that losing an employee and subsequently conducting a search and rehiring for that position can cost an organization one-fifth of that person's annual salary, according to The Center for American Progress. You owe it to your practice to invest just as much work and care in retaining quality staff members, as you do hiring new ones. One way to do that is to offer a competitive benefits package. Many practices can't offer significant raises or bonuses. And most can't compete with the local hospital system. But what you can do is find out what is meaningful to your staff members and then make it happen.

Maybe that will be a dedicated parking spot for those cold, wintry days in Northern Wisconsin. Maybe a flex schedule for new moms? It's up to you to find out. We talked to a number of staffing and practice management experts to identify that magic mix of benefits that will warm your staff members' hearts. Here's what they recommended.

REASONS TO OFFER BENEFITS

In Physicians Practice's 2014 Staff Salary Survey, 87 percent of respondents said they offered their staff paid vacation and sick leave, nearly three-quarters said they offered health insurance, and half offered a retirement plan with an employer match. Dental insurance and short-term disability insurance rounded out the top five benefits that practices said they offer their staff. If the other practices in your community are offering a close facsimile of this type of benefit package and yours doesn't, it will put your hiring manager at a distinct disadvantage.

Joe Capko, a principle with Capko & Morgan, a San Francisco-based consulting firm, says that benefits should be viewed as a significant part of the practice's culture. "We like to think of the benefit package that is offered to employees as one of the components to building, really, a culture of appreciation among the management and the staff," he says.

Here are some other reasons to offer a high-quality benefits package:

• Staff loyalty and retention. Apart from salary and robust benefits, practices can engender staff loyalty by offering small, extra perks that may not cost a lot of money. Even a heartfelt thank you can go a long way to creating happy, loyal staff members. Happy people like to stay where they are, and they also work hard for a practice that appreciates them. If your staff takes ownership of their roles and their commitment to patients, then everyone benefits.

• Strong competitor. Like many other professions, regional healthcare can be a small, intimate community. Everyone pretty much knows everyone else. Sometimes the grass can look greener in the next pasture, especially if your employee is feeling overworked and underappreciated. Offering great benefits, or individually tailored ones, can make your practice a competitive employer that attracts the best employees.

Carol Stryker, principal at Symbiotic Solutions, a Houston-based consulting firm, says it's the "absence" of benefits that will take your practice out of the running for a top-notch employee. "I'm never sure that benefits, with the exception of health benefits, ever attract an employee. … The lack of them can eliminate your practice for consideration," she says.

• Well-qualified staff. The best staff members have their choice of employers, and they will look first at salary and benefits as major determinants in selecting one practice over another. A good compensation package will also help keep the best employees in your camp. Capko says that smaller practices have an advantage over larger ones because, "It's easier for the management to know all of the employees, allowing management to tailor a benefit package that offers the biggest staff benefit per dollar."

COST VS. BENEFIT

Just as highly productive, well-oiled practices tend to staff at higher ratios, those that are willing to spend a bit more on their staff benefits tend to retain top employees. Yes, that means greater expense, but there are ways to find economies of scale. Sometimes you may even be able to join up with a professional association to get more bang for your buck.

Capko says his firm advises administrators to network with other practice administrators, "So, for example, you can very easily find yourself reinventing the wheel. Someone may have already found out, 'Hey, this is great coverage through this professional association,'" he notes.

Stryker says, "Continuing education benefits are huge for people," but she cautions talking to staff first. She adds there's nothing wrong with being transparent and telling your staff that you only have a certain amount of money to spend. Ask them what they want. Spending money on a benefit that's not wanted is a waste, and won't endear you to staff either.

WHAT BENEFITS SHOULD YOU OFFER?

What are some of the perks that great practices offer? And what are the perks that you should slip off your radar? It depends: on your community, your staff, your schedule; even your specialty.

Daniel Bernick, a principal at The Health Care Group, a practice-management consulting firm based in Plymouth Meeting, Pa., says, "The most popular benefits are vacation, sick days, personal days, paid days off — PTO [paid time off] in one form or another is very popular and expected by staff."

Bernick notes that benefits are an important part of any compensation plan, because of the value they bring. "It is a tax-advantaged way of compensating employees," he says.

Aside from paid days off, health benefits are an essential component in most benefit packages. While Capko notes that many practices are spending less on the type of health insurance plan they offer to employees because of financial pressures (like choosing a plan with a greater deductible, or more cost sharing), there are other ways to make it up to employees — for example, offering flex schedules to young parents.

If a practice wants to offer full-time employees a basic benefits package, Bernick says it should include paid vacation time, sick days, personal days, a 401K plan, and health insurance with a cost share. However, he notes that a practice can use discretion in determining how much of a benefit they wish to offer.

"You could offer a larger amount or a smaller amount. Simply because you are offering vacation doesn't mean that you offer six weeks of vacation. You don't necessarily offer a lot of benefits, but at least you provide something in these categories. It is meaningful and people really appreciate it," Bernick says.

Doctors and nurses in the United States are often over worked and extremely busy running between patients and rooms. They frequently need to access systems and applications on numerous computers and workstations, and need to do so quickly in order to view important patient data. Something as simple as logging in could become a headache when it needs to be done multiple times on each computer and becomes more complicated if the credentials are forgotten or the practitioner is locked out.

In addition to being inconvenient, this also leads to systems and applications being un-secure since users may write down their passwords or share accounts with other users.

Not only does this reduce efficiency and security, it also cost hospitals and healthcare organizations a great deal of money. To deal with password issues, they need to have help desk staff available at all times. It also means lost money in productivity time spent waiting to access patient data. One recent study found that time spent dealing with these issues was said to “add up to a productivity loss of $900,000 per year for the typical hospital — or more than $5.1 billion annually across the health care industry.”

Healthcare organizations need to reduce the headache associated with password issues and increase efficiency for clinicians. Simple solutions, such as single sign-on or self-service reset password software, can easily mitigate these issues. A single sign-on solution allows clinicians to have a single set of credentials to log on to a computer or workstation with. Once they log in once, they will automatically be signed into all authorized systems and applications once they are launched. Some software providers offer additional benefits such as fast user switching and “Follow Me.”

Fast user switching simplifies the log in process even further by requiring users to only insert a pass card to gain access. In addition, Follow Me allows users who have opened applications on Citrix and/or Terminal Server to continue their work on another computer. This results in considerable time savings, particularly in the case of specialists who make their rounds among departments.

Self-service password reset software also can greatly assist clinicians. This software allows end users to simply answer a few security questions and have the ability to reset their own passwords without having to contact the helpdesk. For example, South County Hospital in Wakefield, Rhode Island, was one such organization that implemented this type of solution.

Its helpdesk averaged between 20 to 25 password resets a month, each requiring about half an hour to complete. This was time consuming for both the clinician and the helpdesk. Doctors and nurses had to wait to continue with their work until their passwords were reset. With a self-service reset password solution, doctors and nurses can now easily reset their own passwords and get on with their work.

Solutions such as these can save hospitals tons of money and time wasted on password issues. Hospitals and healthcare organizations need to stay current with technology, especially that which can have a great positive impact on both their employees and patients.

The deadline for implementing ICD-10 is rapidly approaching. Providers and practices should be preparing for the transition and approaching the implementation with confidence. They should be doing this even with therecent announcement from CMS on creating a one-year grace period, allowing for flexibility in the claims auditing and quality reporting process during the transition. Addressing the following 11 steps will help assure your practice will be on track for a successful transition on Oct. 1, 2015 and going forward:

1. UNDERSTAND ICD-10

Review the major differences between ICD-9 and ICD-10 and how those differences will affect a clinician’s specialty as well as your organization as a whole. Reviewing the “Official Guidelines for Coding and Reporting” for ICD-10 is a good starting point.

2. CREATE YOUR INTERNAL IMPLEMENTATION AND COMMUNICATION TEAM

Include staff from the administrative and clinical sides of your practice and divide up the work that needs to be accomplished. Make sure you communicate the changes required by ICD-10, both from a workflow standpoint as well as clinical documentation.

3. REVIEW THE IMPACT AREAS OF YOUR PRACTICE AND MODIFY PROCESSES

Consider all the different systems you use, the organizations you exchange data with, as well as what electronic and paper-based workflow processes you use that drive clinical encounters and the billing process. Make sure all of these are updated and/or modified appropriately for ICD-10 compatibility.

4. REACH OUT TO YOUR SOFTWARE VENDORS

Ask vendors about any needed upgrades to use ICD-10, what training (if any) will be needed, and cost estimates. Don’t forget to ask about the ability to concurrently use ICD-9 and ICD-10 and how long you’ll have the ability to do that.

5. DEVELOP YOUR BUDGET

Make sure you consider software and hardware upgrades, education and training costs, the cost of temporary staff during transition should it be needed, changes to printed materials, additional time for documentation review, and the cost of lost coder, clinical and/or revenue cycle staff productivity.

6. CONTACT YOUR CLEARINGHOUSES AND HEALTH PLANS

Ask if all their upgrades to accommodate ICD-10 have been completed and if they haven’t, when they will be. Also ask how they (the clearinghouse and health plans) will help your practice with the transition, when can you test claims and other transitions with ICD-10 codes, and whether they provide a list of any data content changes needed. Don’t forget to ask the health plans when they expect to announce their revised ICD-10-related coverage/payment changes.

7. IMPROVE CLINICAL DOCUMENTATION

This may be one of the most challenging aspects of ICD-10. Identify potential documentation issues by beginning to crosswalk ICD-9 codes to ICD-10 codes. The goal should be to identify any gaps in the documentation that prevent a coder from selecting the appropriate ICD-10 code.

8. TRAIN YOUR STAFF

Identify your education needs. While everyone will need to be trained, not everyone will need to be trained at the same level. Identify who should be trained on what. You will also need to identify the best training mode for each group and the timeframe for providing that training.

9. TEST YOUR SYSTEMS

Testing is critical to success with implementation. Plan for both internal and external testing. This will need to be scheduled, so begin the planning now.

10. PLAN FOR CONTINGENCIES

Every practice needs to plan for decreased staff productivity and prepare for the possibilities of other financial challenges during the initial implementation period. You should set aside some cash reserves for the practice. It may also be wise to consider establishing a line of credit.

Preparing now for the transition to ICD-10 will help ease the burden of compliance on Oct. 1, 2015 and assure you will not have a major disruption in your practice revenue.

11. UNDERSTAND THE ICD-10 GRACE PERIOD

Make sure you familiarize yourself with the new grace period rules, including some key points below. CMS also announced the establishment of a communication center and an ICD-10 ombudsman to help receive and triage physician and provider issues.

Medicare contractors will not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as a valid code from the right family of ICD-10 codes is used. Moreover, physicians will not be subject to audits as a result of ICD-10 coding mistakes during this one-year period.

Physicians will not be penalized under the various CMS quality reporting programs for errors related to the additional specificity of the ICD-10 codes, again as long as a valid ICD-10 code from the right family of codes is used.

If Medicare contractors are unable to process claims within established time limits because of ICD-10 administrative problems, such as contractor system malfunction or implementation problems, CMS may in some cases authorize advance payments to physicians.

Healthcare organizations continue to face unprecedented change. Electronic health records are altering nearly every aspect of the caregiver-patient relationship – not to mention changing caregivers’ workflows with omnipresent tablets, handhelds, wall mounts and mobile carts. Today, nurses are on the front lines of this transformation. During a typical shift, they spend 35 percent of their time on documentation, or 3.5 hours of their workday entering information at a computer. Despite this, a recent survey from HIMSS Analytics found that 71 percent of nurses would not consider going back to paper-based medical records. What’s more, nurse respondents agree that EHR benefits are good for patient safety: 72 percent believe they improve patient safety and avoid medication errors and 73 percent admit they enable collaboration with other clinicians inside their organizations.

Underscoring every EHR implementation is the goal of doing business more efficiently, and the HIMSS Analytics findings demonstrate nurses’ integral role in helping hospitals achieve this. It is of equal importance that administrators understand the complete picture surrounding the complex systems nurses have to master. If the necessary equipment doesn’t fit within their workflow or is uncomfortable to work on, not only will EHR systems never reach their full potential, but they stand to cause physical strain to caregivers. This limits their ability to execute their jobs and can ultimately impact the quality of care patients receive. In order for organizations to maximize their system implementations and investments, they must evaluate their caregivers’ new workflows and embrace supportive design and devices that improves comfort while also allowing them to deliver a similar or improved level of patient care.

Importance of ergonomics

A recent Ergotron report, “How Digital Healthcare Helps and Hurts Nurses,” surveyed 250 full-time US nurses and found that 49 percent report feeling some level of discomfort while inputting charting data into a computer workstation. One of the most important factors to consider when integrating technology into nursing workflow is the ergonomics of the equipment. Ergonomics refers to the application of scientific knowledge to a workplace to improve the well-being and efficiency of workers. Access to ergonomic equipment in the workplace increases workers’ efficiency and productivity, while helping to reduce fatigue, exertion and musculoskeletal disorders – all side effects nurses can experience during a long work shifts. Multiple studies have found that a sound ergonomics program helps reduce the number of workplace injuries and absenteeism, and can contribute to overall employee wellness.

Though technology has brought many wonderful innovations to the healthcare system, it also has the potential to introduce improper ergonomics into many clinical settings. Before EHRs, nurses could work on their charting while seated at a nursing station, giving them a break from their active work day. Now, nurses often stand with a computer on wheels when documenting. If the device does not offer standard ergonomic features – such as broad height-adjustment capabilities to adapt a unit to the correct height of the caregiver or negative tilt keyboards – repeated usage over time will add to the nurse’s physical strain.

What’s more, while nurse pain has been well documented, what’s often not addressed is how this physical discomfort directly affects their patient care, or patient experience. Ergotron’s survey revealed that nurses admit to being less friendly or engaging with patients (22 percent), modifying or limiting their patient interaction on the job if their body is hurting (22 percent) or needing to ask for more assistance from other staff (14 percent).

Patient-centered environment

The survey from HIMSS Analytics also revealed that nurses were less likely to think that EHRs help with efficiency and many responded that EHRs did not allow them to spend more time with patients. To create more patient-centered environments, healthcare facilities must find solutions in which nurses can use technology with ease.

Effectively integrating technology into all aspects of the healthcare environment to enhance the patient experience requires attention to positioning the patient, the caregiver and the technology, into a more favorable Triangle of Care alignment, or what Ergotron calls “Patientricity.” Creating a patient-centered environment that is inclusive of technology is only effective when the needs of the patient and medical staff alike are considered – whether documenting at the bedside or reviewing documentation at the nurses station.

When technology is integrated correctly into clinical workflow, it is beneficial to all involved. It promotes increased interaction, satisfaction, safety and efficiency to the patient-caregiver exchange. The patient not only receives the benefit of the face-to-face connection with the caregiver, but the technology becomes a partner in the exchange. When considering this workflow strategy, stakeholders should consider:

Avoid inappropriate or cumbersome placement of technology that impedes the efficiency of care, such as a computer mounted in a room but the caregivers back is to the patient.

Consider adjustable options that allow caregivers to sit or stand while accessing or inputting data to offer a new level of work flexibility.

Evaluate and better understand the human interaction that needs to take place within the digital workflow.

Understand space constraints to determine whether fixed, permanent and dedicated equipment is required, or whether a mobile solution best serves the care-giving requirements.

When nurses feel good, it improves their ability to deliver higher quality of care. Conversely, injuries and physical discomfort directly affect patient interaction. When asked what nurses would change in their work environment to support the prevention of discomfort, pain or injury to themselves and fellow nurses: 28 percent would add a dedicated ergonomics team to help ensure equipment is supportive to staff, and 28 percent would redesign the physical space in the patient rooms and units to better align with clinical workflow and patient needs.

Despite electronic devices being ubiquitous and important tools in health facilities, technology is not always properly integrated into the healthcare environment to help nurses or patients. There are many benefits to exploring ergonomics and patientricity. Besides the inherent productivity gains associated with an ergonomic investment, it also leads to more satisfied employees and patients, increased access to technology, long-term cost reductions and decreased injuries due to poor ergonomics. In order for nurses to take better care of patients, the healthcare system must first take care of its nurses.

With the increase use of computers, there has also been an increase in injuries from non-ergonomic work environments to do required charting. While this is not something I had ever thought of, on reflection it is very true. Rather than sitting comfortably at a desk with good body alignment, I often stand at a mobile station talking to patients that are behind me as I document. I think developing a plan and team to improve the workspace to be more ergonomic would be very beneficial.

When the SGR bill was passed by the Senate without any ICD-10 implementation delays, the proponents of the new coding set rejoiced. Not only did passage of this bill bring about a stronger formula for Medicare reimbursements but it also meant that the ICD-10 implementation would most likely take place by the scheduled deadline of October 1, 2015.

When President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 into law on April 16, the legislation moved American physicians away from fee-for-service payments toward value-based care and accountable care delivery, according to the Healthcare Information and Management Systems Society (HIMSS).

Additionally, the new SGR bill includes innovative objectives for establishing the meaningful use of certified EHR technology. These payment models will be key for improving population health outcomes throughout the country. The volume-based payment reductions under the prior sustainable growth rate formula will now be altered with a new annual payment update of 0.5 percent through 2019.

By 2019, doctors will be able to choose their reimbursement method among two options: the Merit-Based Incentive Payment System or the Alternative Payment Model. While the Merit-Based Incentive Payment System will depend upon the performance of physicians, doctors who choose the Alternative Payment Model must utilize certified EHR technology standards and authorized quality measures as well as assume financial risk.

The overall push toward value-based care among the federal government, patient advocacy groups, and healthcare providers will require the medical industry to quickly and efficiently transition to the ICD-10 coding set. Documenting patients’ medical histories as well as accurately reporting and coding diagnoses and treatments is vital in the quest to pay for value and enhance population health outcomes across the sector.

The Coalition for ICD-10 also reports on the importance of the ICD-10 implementation in the move toward value-based care, as ICD-9 codes do not have the same capabilities as the newer coding set. While the healthcare community supports the SGR reform bill, many physician groups are still against the ICD-10 implementation and are hoping for additional delays.

However, a move toward measuring and paying for value-based care is not possible without transitioning to a modernized form of diagnostic and procedure coding. In order to accurately measure the value of a healthcare service, it is vital to have the detail available in the ICD-10 coding set, the coalition explains.

One example of the subpar quality of ICD-9 codes involves putting two patients with similar conditions but differing symptoms under the same code while ICD-10 accounts for a variety of divergence among patients. Essentially, ICD-10 codes will include key information about patients and record their medical history more accurately with additional detail.

“Despite opposition to ICD-10 by some physician groups and a few isolated state medical societies, there is general recognition in the medical community that a modern and precise coding system like ICD-10 is essential for measuring and paying for value,” the Coalition for ICD-10 stated. “ICD-9 represents medicine of a bygone era. It cannot support a move to measuring and paying for value. To meet the demands of SGR there can be no further delays in the ICD-10 implementation date.”

Many of the first Apple Watch health IT apps will give doctors faster access to critical information and ease communication between health care providers, while other apps will attempt to get patients more engaged with their health.

Don’t expect doctors to glance at their wrists to view X-rays or a patient’s chart, though. Given the Apple Watch’s screen size, functions that involve text messages work best on the device.

“Doctors get that the watch is a tool to help them deal with information overload,” said Michael Nusimow, CEO of drchrono, which makes EHR (electronic health record) software.

Like many other companies in the health space, drchrono announced its app this week at a large health IT conference put on by the Healthcare Information and Management Systems Society, a nonprofit that looks to use IT to improve medical care. About a dozen companies in the health care industry announced their Apple Watch apps this week.

EHRs can overwhelm a physician with troves of data on a patient, Nusimow said.

With drchrono’s Apple Watch app, doctors can receive relevant and important information, such as when a patient arrives at the office. The app can also provide them with the patient’s vital statistics and pictures.

The watch is better suited for tasks like getting text notifications, while the iPad and iPhone, which drchrono also has apps for, can handle functions that require bigger screens, like reviewing charts, Nusimow said.

Watches are more socially acceptable than smartphones, making them ideal to handle messages and notifications, said Vik Kheterpal, principal at CareEvolution, which develops the technology behind health information exchanges.

CareEvolution worked with health insurance provider Anthem to develop its Apple Watch app, which was announced this week. The app, called cFHR, is designed to provide Anthem customers with timely health information. The app, for example, will remind patients to check their blood pressure or alert them about possible medication interactions.

While the iPhone can complete the same tasks as the Apple Watch, there’s a nuanced difference between the devices, Kheterpal said.

People depend on smartphones to instantly convey information. But as the devices have become larger, people may find them a bit cumbersome to constantly remove from their bag or pocket. Plus, some aspects of smartphones, like the devices inopportunely ringing, are social taboos, he said.

The Apple Watch, by comparison, is an extension of the phone, always on a person’s wrist and reliably delivers notifications, Kheterpal said.

The Apple Watch won’t replace the iPhone, said Nate Gross, co-founder of Doximity, a startup that operates a social network for U.S. physicians.

With its app, Doximity was looking to offload some functions to the watch, but save a majority of the tasks for the iPhone.

“We focused on messaging because in the clinical setting, there are a number of times when you just don’t want to take out your phone to start texting,” said Gross.

In some situations, doctors may find that speaking is a better option that typing, he said. For instance, they may prefer to dictate patient notes instead of type them into an iPhone.

While an iPhone app can receive messages, doctors may not hear the phone or feel it vibrate if they place the device in their pocket or lab coat, said Gross.

Doximity’s app, which was announced last week, allows physicians to view messages sent to them from other doctors who use the company’s social network and also to receive alerts when a fax arrives.

In health care, “time is tissue” and delivering alerts to a person’s wrist may help a doctor view an urgent message more quickly, he said.

Some physicians who work long hours may need to extend the Apple Watch’s 18-hour battery life to the get the most from their health IT apps, Gross added. Emergency room doctors and medical residents can work 24-hour shifts.

Some may purchase third-party watch bands equipped with batteries while others will charge the device during their shifts, he said.

“We will see friction occur on battery life for very specific doctors rather than doctors as a whole,” said Gross. Physicians aren’t accustomed to owning watches that require nightly charging, he added.

Releasing physician notes to patients is scary for many doctors. Common concerns include patient misunderstandings regarding the health information included in the note, damaged physician-patient relationships due to the content included, and a flood of questions from patients who are confused about clinical terminology.

1. More patients want — and expect — access to physician notes.During the presentation, Walker shared results from a one-year Open Notes demonstration project funded by the Robert Wood Johnson Foundation. About 100 physicians from Beth Israel Deaconess Medical Center, Geisinger Health System, and Harborview Medical Center participated in the project, affecting more than 13,000 patients in multiple locations.

Jan Walker In the demonstration project, patients received an alert that their note was ready to view as soon as the physician signed the note (and they received another alert prior to patient visits).

Walker acknowledged that one big question prior to starting the project was whether patients would be interested. Ultimately, over the course of the 12-months, 82 percent of patients at Geisinger who had a visit to their provider opened at least one note.

Notably, that included older patients, sicker patients, and less educated patients. In fact, patients with no more than a high school education looked at notes at same rate as everyone else, said Walker.

Ninety nine percent of patients said they wanted to continue having access to physician notes, and 85 percent said availability of physician notes would influence their future choice of providers.

2. Patients report positive results when they can view physician notes.So what effect did that increased access to physician notes have on patients? The study suggests a positive one. About three-quarters of the survey respondents said they take better care of themselves, understand their health better, feel more in control, take their meds as prescribed at greater rates, and feel better prepared for patient visits, said Walker.

Other positive results Walker said patients reported included:

• Improved recall of the patient visit and improved ability to adhere to follow-up recommendations, because looking at the note helped patients refresh their memory.

• Improved trust between patients and their physicians because it removed the "mystery" of what the physician was writing in the record.

• Improved ability of patients to be prepared for their next visit and to engage in shared decision making.

3. Physicians report positive results when patients can view their notes.While many of the physicians reported concerns regarding how patient access to notes would affect their work flow, very few actually saw these concerns come to fruition, according to Walker.

Only 2 percent reported longer visits, 3 percent reported spending more time on patient questions, and 11 percent reported spending more time on documentation. In fact, Walker commented that a common question received from physicians who were participating in the demonstration was whether the access to physician notes feature was on, because they weren't getting questions from patients about the notes.

And, contrary to the fear that patients might be confused, unnecessarily worried, or offended by the notes, only one percent to eight percent of physicians reported these problems, said Walker.

Perhaps most telling is that, at the end of the 12-month demonstration, none of the participating primary-care physicians stopped participation, even though that was an option. "We really believe this is the right thing to do," said Walker.

Life is tough for physicians in solo and small group practice. The federally mandated introduction this fall of ICD-10 requires physicians and their staffs to learn a new system of coding diseases. “Meaningful Use,” another federal program, requires physicians to install and use electronic health records systems, which are complex and expensive. And PQRS, the Physician Quality Reporting System, is beginning to penalize physicians for failing to report individual data for up to 110 quality measures, such as patient immunizations, each of which takes time to collect and record.

Of course, such requirements are not being imposed solely on solo and small-group physicians. In many ways, they affect all physicians alike. Yet the burdens of complying are disproportionately high for small groups, which cannot spread out the costs of purchasing equipment, hiring employees and consultants, and training personnel over so large a number of colleagues. Hospitals and large medical groups can afford to hire full-time specialists to meet these challenges, but such approaches are not economically feasible for a group that consists of only a few physicians.

Such challenges are not just raining down – they are pouring down on the heads of physicians. Some physicians fear they smell a conspiracy to drive solo and small-group practitioners out of business. And the problem is not just the money. It’s also the time. Many physicians already work long hours and simply cannot afford to shop for such systems, negotiate contracts, and enter data. We personally know physicians who report spending two hours each evening completing records that they did not have time to attend to while they were seeing patients.

Not surprisingly, independent physicians appear to be going the way of the dinosaurs. One study found that only 17 percent of today’s physicians are in solo practice, a figure that stood at 54 percent in 1980. Moreover, the percentage of physicians who describe themselves as independent practice owners has dropped from 62 percent in 2008 to just 35 percent last year, manifesting an acceleration in the pace of decline. Conversely, over the same period, the percentage who say there are now employees of a hospital or medical group has increased from 38 percent to 53 percent.

We recently spoke with Georgia Blobaum, a medical practice administrator in Lincoln, Nebraska. Blobaum has worked with many independent physicians who are now spending so much time trying to comply with mandates of the federal government, insurance companies, and hospitals that they have little energy left to care for patients. “My heart really goes out to these doctors,” says Blobaum. “They find the whole thing just so wearying. They want to do right by their patients, but big organizations are making life so difficult for them that many are just throwing up their hands in frustration.”

Blobaum says many hospitals and health systems are seizing this decline in morale as an opportunity to snap up small physician practices. “They know how discouraged physicians get when they contemplate all the work necessary to implement their own electronic health systems. Then in comes a hospital who says that they will take care of all the IT and paperwork, and pay the physician more than they are currently making to boot. Only two to three years later do physicians realize that their new employer is just piling on even more requirements and cutting their salary.”

“What is even worse,” Blobaum continues, “is that these physicians are giving up their autonomy. I was talking recently to an oncologist. He said that if he sells his practice to the local hospital, it will penalize him unless he refers all his patients to its facility and the physicians it employs. But he thinks this is not always the best thing to do. He knows his patients and he knows his colleagues. If he thinks a particular physician is a good match for a patient, he wants the freedom to refer to that colleague, without regard to who he or she happens to work for. For this reason, he will not sell.”

“Too often,” says Blobaum, “health systems deliver independent physicians an ultimatum: ‘Either you join us as an employed physician, or we will replace you with other physicians who are eager to have your job.’” Blobaum believes this is one of the greatest sources of the decline in contemporary physician morale – physicians are being made to feel alone, isolated, and unable to continue to operate independently. “As a gastroenterologist told me recently,” she continues, “physicians are growing so accustomed to being told what to do that many have seem to have become paralyzed.”

Physicians in Nebraska are so concerned that they have formed a new organization of independent physicians. Called OneHealth Nebraska, it helps to lower the costs of operating a medical practice by pooling resources. For example, it will offer consolidated credentialing, so each physician does not need to fill out pages of forms for every hospital and insurance company. It will also offer its members access to group purchasing and training, quality and compliance monitoring, and practice management services. The hope is that independent physicians can keep practicing independently.

So far, the group has signed up more than 300 Nebraska physicians, and it is continuing to grow rapidly. Blobaum explains it this way: “What we are talking about here is not a union, with collective bargaining and the right to strike. But it does represent the unification of physicians around something many of them believe in deeply; namely, the mission of preserving the independent practice of medicine by enabling physicians to continue to focus their attention on delivering high-quality, patient-focused care.”

“Our members believe that physician independence is a crucial ingredient in the recipe for high-quality healthcare,” says Blobaum. “We admit that the pressures on physicians to give up ownership of their medical practices are huge, but we also believe that it is important to for them to maintain their independence. By banding together and pooling their experiences and resources, physicians can put themselves in a much better position to put the interests of patients first, which is ultimately what makes practicing medicine rewarding in the first place.”

For the report, Black Book surveyed 14,000 nurses and 5,000 hospital staff members across 702 hospitals with EHR systems between August 2014 and February 2015.

The rankings are based on the client experience scores for:

Accountable care organizations' data needs;

Add-on modules;

Administrative and documentation functionalities;

Certification-required EHR functionalities;

Clinical workflow functionalities; and

Connectivity capabilities.

Top Inpatient EHR Vendors

EHR vendors that received the highest scores for customer experience are:

CPSI for rural, critical access and hospitals with fewer than 100 beds;

Cerner for community hospitals with between 101 and 250 beds; and

Allscripts for hospitals with more than 250 beds.

Meanwhile, Cerner was selected by hospital IT managers and CIOs as the best EHR for hospitals.

Increase in Nurses' Satisfaction With EHR Systems

Meanwhile, CIO respondents reported an increase in nurses' satisfaction with EHR systems. Among hospital IT leaders:

69% said that the increase in nurses' satisfaction was the result of nurses' EHR concerns being heard and addressed through system updates;

20% attributed the increase to improved EHR functionality and system updates; and

10% attributed the increase to adjustments in EHR use and training.

Black Book Managing Partner Doug Brown said that the "findings included a substantial improvement in reducing the gap between hospital nursing, physician, administrative, financial and technology stakeholder satisfaction, although there's still a long way to go".

Nurses at a California hospital are asking state officials to investigate the failure of the hospital's electronic medical recordsystem, an incident they said led to the closure of its emergency room and compromised patient safety.

The EMR system at the 420-bed Antelope Valley Hospital in Lancaster, California, reportedly failed last weekend, resulting in clinicians unable to review patient labs, verify physician orders and access patient records, according to the California Nurses Association and the National Nurses United union.

"Our entire electronic and data system failed," Feb. 27 wrote Antelope Valley's Maria Altamirano, RN, on behalf of California Nurses Association, in a letter to the Los Angeles County Department of Public Health. Due to the failure, the hospital, Altamirano explained, had to close its emergency department because it failed to have adequate backup plans in place.

"How many hospitals are compromising the lives of their patients by not having a back up or plan of action in place for a catastrophic event as this?" she asked.

The hospital's pharmacy system and its backup also crashed, according to an emailed statement from a CNA spokesperson.

However, according to hospital officials, downtime procedures were indeed in place and utilized, said Dennis Knox, chief executive officer at Antelope Valley Hospital, in an emailed statement. When the EMR outage occurred Friday, Feb. 27, hospital officials took immediate steps to bring the system back online. The system was fully working again on March 1.

Clinicians were able to resort to hand-written medical record keeping, and despite the EMR being down, the hospital was still able to process medication orders and lab results, Knox explained. What's more, although medication requests were processed via hand-written paper orders, the prescription management system was on a server unaffected by the outage, and thus the pharmacy could continue filling those orders.

Knox acknowledged that there were times during the outage when they had to send certain patients to nearby facilities for treatment, but its emergency department did continue to treat patients.

"Our team of professionals worked tirelessly throughout the weekend to process lab orders and results, review radiology exams, carry out treatment plans and deliver overall patient care as promptly as possible," added Knox.

National Nurses United, the largest registered nurses union in the U.S. with some 185,000 members, in the last few years has criticized specific hospitals' use of EMR systems, platforms that have significant downtime, fail or are not designed well for clinician users.

As NNU Spokesperson Liz Jacobs told Healthcare IT News back in 2013: "We're not anti-technology." Rather, "we want smart technology that embraces and includes the clinicalexpertise of a registered nurse who really knows how best to put together a system that will work for them."

The union also spoke up in a similar EMR outage back in August 2013when Sutter Health's $1 billion EMR system went dark for a day, preventing clinicians from accessing patient medical records and seeing medication orders.

"This caused intermittent access challenges in some locations," said Sutter Health Spokesperson Bill Gleeson in an emailed statement to Healthcare IT News of the incident.

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